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Patent Ductus Arteriosus: Clinical manifestation and Diagnosis
- 1. NHF Cardiac Course Patent Ductus Arteriosus: Clinical features and Diagnosis Dr. Shahreen Kabir FCPS (PAED) Registrar Pediatric Cardiology NHF&RI
- 3. NHF Cardiac Course Flow through PDA depends on… Size and resistance of Ductus PVR:SVR PVR SVR PVR: Pulmonary Vascular Resistance SVR: Systemic Vascular Resistance
- 4. NHF Cardiac Course Hemodynamic changes At birth • High PVR, minimal L-R shunt, less symptoms At 6-8 weeks • PVR falls, increase in L-R shunts(Qp), symptoms starts, PAH starts to develop With time • PVR gradually rises • PVOD develops • Right Ventricular failure
- 5. NHF Cardiac Course • Blood flows from Aorta to PA both in systole and diastole • Increase in Qp • Increased Pulmonary venous return to LA
- 6. NHF Cardiac Course • Increase in preload • LV increases its stroke volume • Dilatation and hypertrophy of LV • Dilatation of Aorta
- 7. NHF Cardiac Course History Key points Prematurity Maternal rash in the first trimester High altitude Down syndrome/ Edward Syndrome/ Char syndrome
- 8. NHF Cardiac Course Congenital Rubella Syndrome Cataract Hearing Defect Heart Defect: PDA
- 9. NHF Cardiac Course Hemodynamic classification of PDA PDA Small PDA Moderate PDA Large • Qp/Qs: <1.5 • LA/LV not dilated • Normal PA pressure • Shunt depends on the size of the PDA • Qp/Qs: >1.5-2 • LA/LV dilated • PA pressure mildly elevated /normal • Shunts depend on PVR:SVR ratio • Qp/Qs: >2 • LA/LV dilated • PA pressure elevated
- 10. NHF Cardiac Course Neonatal presentation Common Presentation Respiratory Distress Feeding Difficulty Diaphoresis Shock IVH Necrotizing Enterocolitis Signs Syndromic facies Microcephaly Cataract Tachypnoea Tachycardia Signs Bounding pulses Hypotension with widened pulse pressure Not “typical” Continuous Murmur Crackles at lung bases
- 11. NHF Cardiac Course • Asymptomatic • Incidental detection of systolic/ continuous murmur • Unremarkable ECG and Chest Xray Small PDA Silent PDA • Too tiny to produce murmur • Diagnosed by echocardiography
- 12. NHF Cardiac Course Moderate PDA • Frequent RTI • Respiratory distress • Diaphoresis • Poor feeding • Not growing well • Exertional fatigue Symptoms • Mild failure to thrive • Bounding pulses • Wide pulse pressure Signs • Mildly overactive precordium • Shifted apex beat • Thrill at left upper chest • Continuous machinery murmur Precordial findings
- 13. NHF Cardiac Course Large PDA • Will be similar to that of moderate PDA, but the severity is more. Symptoms • Severe failure to thrive • Bounding pulses • Wide pulse pressure • CHF Signs • Hyperdynamic precordium, chest deformity • Forceful ill-sustained shifted apex • Thrill at left upper chest • P2 palpable, Loud S2 • Short systolic murmur, MDM, S3 Precordial Findings
- 14. NHF Cardiac Course But…. Differential Cyanosis PVR SVR Picture taken with parental consent
- 15. NHF Cardiac Course Eisenmenger Physiology Symptoms • Less frequent episodes of RTI • Leg “fatigue” • Duskiness of the toes, with pink fingers Signs • Sat UL- Normal LL- <90% • Toes- clubbed • Features of right heart failure Precordium • Apex not shifted • Single S2,Loud P2 • Continuous PDA murmur not found • Mid-diastolic murmur of PR
- 16. NHF Cardiac Course Physical findings…explained Wide Pulse Pressure: • Increase in the preload of LV Increase stroke volume into the aorta Aortic systolic pressure is elevated • The diastolic pressure is lowered because of a good amount of blood flow into the PA and not the descending Aorta (Diastolic run-off) Ref: Pocket book of Pediatric Cardiology, 2nd Ed
- 17. NHF Cardiac Course The Continuous machinery murmur described by Gibson: • Begins after S1 • Rises to a peak in late systole, near S2 • Continuous through second heart sound, uninterrupted into diastole • Declines in intensity during the course of diastole • Multiple clicks Ref: Pocket book of Pediatric Cardiology, 2nd Ed
- 18. NHF Cardiac Course • The duration of diastolic murmur of the PDA reflects the PA pressure As the PVR rises the PA and Ao diastolic pressure equalizes. The duration of the diastolic murmur shortens leaving a holosystolic murmur. With Right to Left shunt, the ductus is “Silent”. With increasing PVR, the systolic portion of murmur shortens
- 19. NHF Cardiac Course Mid-diastolic murmur: • An apical mid-diastolic murmur suggests a large left-to-right shunt through the PDA, resulting in a large volume of blood flow crossing a normal mitral valve. • This murmur cannot be heard unless the diastolic portion of the continuous murmur is decreased by an increase in PVR. REF:POCKET GUIDE PEDIATRIC CARDIOLOGY PERLOFF’S CLINICAL RECOGNITION OF CONGENITAL HEART DISEASE, 6TH ED
- 20. NHF Cardiac Course • The second heart sound is “paradoxical” in PDA, • The A2 component closes later than the P2 component as it takes more time to eject more blood from the LV • The RV ejecting less blood than the LV, closes early
- 21. NHF Cardiac Course Diagnostic Work up • Chest X-ray • ECG • Echocardiography • Multi slice cardiac CT with CT Angiogram • Cardiac Catheterization
- 22. NHF Cardiac Course Chest Xray
- 23. NHF Cardiac Course ECG • Normal sinus rhythm • H/R 100/min • Normal Axis • LA enlargement: Bifid or Biphasic P waves • LV hypertrophy • Deep Q waves
- 24. NHF Cardiac Course • Echocardiography is an efficient tool for diagnosis and evaluation for PDA. • Cardiac catheterization done when….
- 25. NHF Cardiac Course Cardiac Catheterization… when to do it? Diagnosis Shunt Magnitiude PVRI:SVRI Additional lesions, eg Co-Arctaion Therapeutic (Device closure)
- 26. NHF Cardiac Course Catheter Trajectory Venous Access: IVC RA RV PA Ao Catheter easily passes from PA to Ao through PDA Takes a specific “Hair Pin” appearance
- 27. NHF Cardiac Course • Pressure Measurement: RA RV Individual branch PA MPA pressure tends to be higher if the catheter tip is near the orifice The descending aortic pressure is recorded after the duct is crossed. • Oxymtery: RV to PA step up usually confirms PDA. A step up of 6% is taken to be significant
- 28. NHF Cardiac Course • Arterial Access: Aortography: for visualization and assessment of PDA and any associated Co- arctation LV graphy : to see any associated VSD
- 29. NHF Cardiac Course Choice of view Left lateral ( 90 degree) Right Anterior oblique view(45◦) degree)
- 30. NHF Cardiac Course Haemodynamic data Site Without O2 With O2 SO2 Pressure SO2 Pressure SVC 76 82 IVC 68 71 RA 74 80 RV 76 82 PA 82 100/53/67 90 100/48/66 AO 91.7 100/55/70 98.1 105/67/88 PV 99 100 Parameter Without Oxygen With Oxygen L/min/m2 BSA QP 7.18 13.8 QS 5.49 5.44 Qp : Qs 1.3:1 2.54 PVRI 7.94 4.49 SVRI 11.29WU 15.07WU PVR/SVR 0.703 0.313 FLOW AND RESISTENCE CALCULATION
- 32. NHF Cardiac Course Multislice CT Scan
- 33. NHF Cardiac Course Differential Diagnosis Points in favor Points against Aorto Pulmonary Window • Bounding Pulse, Wide Pulse P • Continuous machinery murmur • Murmur found in left 3rd ICS • Louder systolic component • Clicks not found • Does not peak at S2. RSOV • Continuous murmur • Bounding Pulse • Murmur intensity maximum 4/6 in PDA • Murmur at mid to lower sternal border on left and right side • Intensity 5 or 6/6 • Highly palpable thrill VSD with AR Bounding pulses Wide pulse pressure Systolic murmur • Murmur not continuous when heard below the clavicle
- 34. NHF Cardiac Course Natural history • The PDA becomes anatomically closed by 15 hours of birth and functionally closes off by 24-48 post natal hours • It closes off by the first month in the term neonates, if at all. • For the preterm babies, it takes a little longer, appropriately with the corrected gestational age. • The ductus is more likely to close off in a preterm baby because the ductual smooth muscle is less responsive to oxygen. • But in term babies the ductus is patent due to structural abnormality
- 35. NHF Cardiac Course • Within early infancy a moderate/large PDA will cause CHF and recurrent RTI if left untreated. • If not timely closed large PDA can develop Eisenmenger syndrome, even in the first decade. • Although rare in this era, the narrow pulmonary end of the PDA can develop infected endarteritis, which can dislodge and flow to lungs • A rare complication after device/ surgical closure of PDA is ductal aneurysm or rupture.
- 36. NHF Cardiac Course Other lesions associated with PDA • Co-Arctation • Bicuspid Aortic Valve • ASD • VSD • AVSD
- 37. NHF Cardiac Course Duct dependent Lesions:
- 38. NHF Cardiac Course Duct Dependent Pulmonary Blood flow • Pulmonary Atresia • Critical Pulmonary Stenosis • TOF with severe PS • Tricuspid Atresia • Severe Ebstein Anomaly
- 39. NHF Cardiac Course Duct Dependent Systemic Blood flow • Severe coarctation of aorta • Critical aortic stenosis • Interrupted aortic arch • Hypoplastic left heart syndrome
- 40. NHF Cardiac Course Duct Dependent Pulmonary & Systemic flow Transposition of Great Arteries